Impact of Aortic Valve Replacement for Aortic Stenosis on Coexisting Mitral Stenosis

Purpose: The course of coexisting mitral valve stenosis is not clear after aortic valve replacement (AVR) for aortic stenosis (AS). We investigated the effect of AVR for AS on coexisting mitral stenosis (MS).Methods: Between January 2002 and December 2019, 1338 consecutive patients underwent surgical AVR at Shiga University of Medical Science. Of them, 34 patients with moderate MS (mitral valve area [MVA]: 1.5–2.0 cm²) were included in the present study. We evaluated the postoperative clinical outcomes in these patients.Results: Mean MVA in our cohort significantly increased 1 week after operation compared with preoperative values, and the change was maintained for 5 years after surgery. Follow-up was completed in 94.1% (32/34) patients, and mean follow-up duration was 4.0 ± 3.0 years. No patients underwent mitral surgery for remaining MS after AVR during postoperative follow-up.Conclusion: AVR for AS resulted in increased MVA in patients with MS, and the change was maintained during follow-up.     

Transcatheter and Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valve Stenosis

BackgroundTranscatheter aortic valve replacement (TAVR) is not widely used in patients with bicuspid aortic valve (BAV) disease and has not yet been studied in randomized clinical trials. We characterized the rate of use and outcomes of TAVR and surgical aortic valve replacement (SAVR) in patients with BAV.MethodsAdults with BAV stenosis receiving SAVR or TAVR procedures were abstracted from the 2012 to 2019 Nationwide Readmissions Database (NRD). Risk-adjusted analyses were performed with NRD-provided weights and inverse probability of treatment weights (IPTW) to examine the association of treatment strategy on inpatient mortality, complications, and hospitalization resource utilization. Nonelective readmissions within 90 days of discharge and reintervention at the first readmission were also examined.ResultsOf an estimated 56 331 patients with BAV requiring aortic valve replacement, 6.8% underwent TAVR. Unadjusted analysis demonstrated higher index hospitalization mortality for TAVR compared with SAVR. Upon risk adjustment using NRD-provided weights, the odds of pacemaker implantation remained significantly higher for TAVR patients compared with SAVR, with no significant difference in mortality. When NRD-provided survey weights were applied, TAVR had higher rates of 90-day readmission. Adjustment with inverse probability of treatment weights resolved these differences between the 2 groups. Regardless of the risk-adjustment method, the odds of reintervention were consistently higher among BAV TAVR patients compared with SAVR.ConclusionsThe present analysis demonstrates comparable in-hospital mortality and morbidity for TAVR and SAVR patients in the moderate-risk era. With increasing TAVR use in BAV, surgeons must further refine selection criteria with consideration of concomitant aortopathy and implications of reintervention.     

Aortic Valve Replacement for Aortic Stenosis with a Small Mechanical Prosthetic Valve

ABSTRACT Background: Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is recognized that the use of small prosthetic valves due to a small aortic root often affects postoperative course after AVR. The aim of this study was to determine whether the use of small prosthetic valves was a risk factor of AVR for AS. Methods: We compared various perioperative factors and operative outcomes between patients with a small mechanical prosthetic valve (small group) and patients with a large mechanical prosthetic valve (large group). Results: Early mortality was 0% in each group and the 5-year mortality was 25% in the small group and 10% in the large group. There were no significant differences in perioperative factors between the two groups. The small group patients were significantly older and smaller compared to the large group patients. The valve size was significantly correlated with age and BSA. Conclusions: The use of small mechanical prostheses was not a risk factor of AVR for AS when it was proportionate to the BSA even for elderly patients. AVR using a small mechanical prosthetic valve may be performed with good results in the short-and long-term.     

Reversal of Advanced Left Ventricular Dysfunction Following Aortic Valve Replacement for Aortic Stenosis

A series of 12 consecutive patients who underwent aortic valve replacement (AVR) for aortic stenosis complicated by severe left ventricular dysfunction was reviewed. Ventricular dysfunction was reflected by pulmonary congestion, edema, renal and hepatic dysfunction, and by severely depressed ejection fractions (mean, 13%; range=0-20%). Aortic valve replacement was accompanied by mitral commissurotomy in 1 patient and aortocoronary bypass in 5. Three of 5 patients with greater than 50% coronary obstruction died without reversal of heart failure, and 1 of the 5 died after a stroke. The 1 survivor of this group has done well.All 7 patients with minimal or no coronary disease survived operation and are now in New York Heart Association Class I or II. Postoperative catheterization (2 to 12 months) in 6 patients showed improved cardiac index and filling pressures. Left ventricular diastolic volume fell from 159 to 82 ml/m², and ejection fraction rose from 13 to 45%. We conclude that left ventricular dysfunction owing to aortic stenosis alone is reversible and that AVR results in great clinical improvement. When coronary disease is present, survival may be accompanied by great improvement but the operative mortality is much higher.     

Coronary Artery Stenosis Following Aortic Valve Replacement and Intermittent Intracoronary Cardioplegia

From July, 1977, to July, 1980, intermittent cold blood potassium cardioplegia was used in 208 patients undergoing aortic valve replacement. Aortic root injection of the cardioplegic solution at 10°C was followed every 20 to 30 minutes by infusions of the solution through Silastic cannulas sutured in the coronary orifices or reinserted with each injection.Symptoms of myocardial ischemia developed in 6 patients 3 to 30 months postoperatively. Coronary angiography confirmed new stenoses of the left orifice (3 patients), left main trunk (1 patient), left anterior descending coronary artery (2 patients), circumflex coronary artery (1 patient), and right orifice (3 patients). Four patients underwent saphenous vein grafting procedures, with 2 deaths; 2 patients refused reoperation. A seventh patient with 80% stenosis of the circumflex coronary artery and a posterolateral myocardial infarction died 2 months after double-valve replacement.Intermittent cold blood potassium cardioplegia instead of continuous perfusion did not prevent coronary arterial injury. Injuries occurred in the distal coronary arteries as well as the orifices and were not prevented by withdrawal of the cannulas between injections. Tight-fitting cannulas and high-pressure injection should be avoided. A careful search for coronary arterial injury should be made in all symptomatic patients following aortic valve replacement.